Centers for Medicare Medicaid Services CMS’ Progress Toward Implementing Value Based Purchasing Thomas B Valuck MD JD Medical Officer Senior Adviser

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Centers for Medicare Medicaid Services CMS’ Progress Toward Implementing Value Based Purchasing Thomas B Valuck MD JD Medical Officer Senior Adviser Powered By Docstoc
					Centers for Medicare & Medicaid Services




    CMS’ Progress Toward
        Implementing
   Value-Based Purchasing

      Thomas B. Valuck, MD, JD
         Medical Officer & Senior Adviser
         Center for Medicare Management
   Presentation Overview


CMS’ Value-Based Purchasing (VBP)
Principles
CMS’ VBP Demonstrations and Pilots
CMS’ VBP Programs
Value-Driven Health Care
Horizon Scanning and Opportunities for
Participation
CMS’ Quality Improvement Roadmap


    Vision: The right care for every person
    every time
      Make care:
        Safe
        Effective
        Efficient
        Patient-centered
        Timely
        Equitable
CMS’ Quality Improvement Roadmap


    Strategies
      Work through partnerships
      Measure quality and report comparative results
      Value-Based Purchasing: improve quality and
      avoid unnecessary costs
      Encourage adoption of effective health
      information technology
      Promote innovation and the evidence base for
      effective use of technology
     VBP Program Goals

Improve clinical quality
Reduce adverse events and improve patient
safety
Encourage more patient-centered care
Avoid unnecessary costs in the delivery of
care
Stimulate investments in effective structural
components or systems
Make performance results transparent and
comprehensible
   To empower consumers to make value-based
   decisions about their health care
   To encourage hospitals and clinicians to improve
   quality of care the quality of care
What Does VBP Mean to CMS?


Transforming Medicare from a passive payer to an
active purchaser of higher quality, more efficient
health care
Tools and initiatives for promoting better quality, while
avoiding unnecessary costs
   Tools: measurement, payment incentives, public reporting,
   conditions of participation, coverage policy, QIO program

   Initiatives: pay for reporting, pay for performance,
   gainsharing, competitive bidding, coverage decisions, direct
   provider support
              Why VBP?

Improve Quality
  Quality improvement opportunity
     Wennberg’s Dartmouth Atlas on variation in care
     McGlynn’s NEJM findings on lack of evidence-based care
     IOM’s Crossing the Quality Chasm findings

Avoid Unnecessary Costs
  Medicare’s various fee-for-service fee schedules and
  prospective payment systems are based on resource
  consumption and quantity of care, NOT quality or
  unnecessary costs avoided
     Physician Fee Schedule and Hospital Inpatient DRGs
     Medicare Trust Fund insolvency looms
Practice Variation
Practice Variation
            Support for VBP

President’s Budget
   FYs 2006-09
Congressional Interest in P4P and Other Value-Based
Purchasing Tools
   BIPA, MMA, DRA, TRCHA, MMSEA
MedPAC Reports to Congress
   P4P recommendations related to quality, efficiency, health
   information technology, and payment reform
IOM Reports
   P4P recommendations in To Err Is Human and Crossing the
   Quality Chasm
   Report, Rewarding Provider Performance: Aligning Incentives in
   Medicare
Private Sector
   Private health plans
   Employer coalitions
VBP Demonstrations and Pilots

 Premier Hospital Quality Incentive
 Demonstration
 Physician Group Practice Demonstration
 Medicare Care Management Performance
 Demonstration
 Nursing Home Value-Based Purchasing
 Demonstration
 Home Health Pay-for-Performance
 Demonstration
 ESRD Bundled Payment Demonstration
 ESRD Disease Management Demonstration
VBP Demonstrations and Pilots

Medicare Health Support Pilots
Care Management for High-Cost Beneficiaries
Demonstration
Medicare Healthcare Quality Demonstration
Gainsharing Demonstrations
Better Quality Information (BQI) Pilots
Electronic Health Records (EHR) Demonstration
Medical Home Demonstration
                        Premier Hospital Quality
                        Incentive Demonstration
                   CMS/Premier HQID Project Participants Composite Quality Score:
                         Trend of Quarterly Median (5th Decile) by Clinical Focus Area
            October 1, 2003 - September 30, 2006 (Year 1 and Year 2 Final Data, and Yr 3 Preliminary)


100%




                                           98.44%
                                           98.28%

                                         98.3777%




                                                                                                                                              97.7264%
                                                                                                                                                97.50%
                                         97.01%
95%
                96.84%
              96.7644%




                                         96.77%




                                                                                                                                               96.89%
                                        96.16%
               96.14%




                                                                                                                                              96.05%
               95.98%




                                                                                                                                              95.92%
               95.77%




                                                                                                                                             95.20%
              95.08%




                                      94.89%
                                     93.70%
            93.50%
            93.36%




                                                                                                                                           93.40%
           92.55%




90%




                                                                                                                                         91.63%
         91.50%




                                                                            91.4013%




                                                                                                                                        90.93%
                                 90.57%




                                                                             90.09%




                                                                                                                        90.00%
       89.95%




                                                                                                                     89.9371%
       89.62%




                                89.45%




                                                                            89.28%




                                                                                                                       88.79%




                                                                                                                                     88.68%
                                                                           88.54%
85%




                                                                                                                    86.73%




                                                                                                                                   86.69%
                                                                        86.30%
                            85.92%
                           85.14%




                                                                                                                                 85.13%
                                                                      84.81%




                                                                                                                 84.38%
                                                                                                               82.98%
                                                                    82.72%
                                                                   82.49%
80%




                                                                                                             81.57%
                                                                80.00%




                                                                                                         78.22%
                                                              78.07%
75%




                                                                                                      76.14%
                                                        73.06%




                                                                                                  73.05%
70%
                                                    70.00%




                                                                                            68.11%
65%




                                                                                       63.96%
60%

55%
             AMI                   CABG                      Pneumonia                           Heart Failure                        Hip and Knee

                                                     Clinical Focus Area
            4Q03    1Q04    2Q04    3Q04     4Q04       1Q05        2Q05        3Q05          4Q05           1Q06           2Q06      3Q06
         VBP Initiatives


Hospital Quality Initiative: Inpatient & Outpatient
Hospital VBP Plan & Report to Congress
Hospital-Acquired Conditions & Present on Admission
Indicator
Physician Voluntary Reporting Program
Physician Quality Reporting Initiative
Physician Resource Use
Home Health Care Pay for Reporting
Medicaid
  VBP Initiatives




Hospital Value-Based
     Purchasing
    Hospital Quality Initiative


• MMA Section 501(b)
  – Payment differential of 0.4% for reporting
    (hospital pay for reporting)
  – FYs 2005-07
  – Starter set of 10 measures
  – High participation rate (>98%) for small incentive
  – Public reporting through CMS’ Hospital Compare
    website
       Hospital Quality Initiative

• DRA Section 5001(a)
   – Payment differential of 2% for reporting (hospital P4R)
   – FYs 2007- “subsequent years”
   – Expanded measure set, based on IOM’s December 2005
     Performance Measures Report
   – Expanded measures publicly reported through CMS’
     Hospital Compare website

• DRA Section 5001(b)
   – Report for hospital VBP beginning with FY 2009
      • Report must consider: quality and cost measure
        development and refinement, data infrastructure, payment
        methodology, and public reporting
      Legislative Background

Deficit Reduction Act (DRA) Section 5001(b) authorized
CMS to develop a Medicare Hospital VBP Plan
  IPPS hospitals
  Assumption of FY 2009 start date
  Must consider
      Measures
      Data infrastructure and validation
      Incentive structure
      Public reporting
  Must consult stakeholders and consider experience with
  relevant demonstrations and private-sector programs
      Hospital VBP Plan
     Development Process
Hospital VBP Workgroup with Subgroups to
address
  Incentive Structure
  Measures
  Data Infrastructure and Validation
  Public Reporting

Contractor Support
  RAND for overall project
  Brandeis, Booz|Allen|Hamilton, and Boston
  University for in-depth measures issues

                                              5
         Hospital VBP Workgroup
            Tasks & Timeline
 2006
 Oct       Environmental Scan
 Dec       Issues Paper
 2007      Listening Session #1 for
Jan 17     Stakeholder Input on Issues Paper
           Options Paper
Apr 12     Listening Session #2 for Input on
           Hospital VBP Options Paper
 May       Final Design
 June      Final Report, Including Design,
           Process, and Environmental Scan
Nov 21     Report Submitted to Congress
                                               6
Performance Model Overview

Hospitals submit data for all VBP measures that apply

CMS determines each hospital’s performance score on each
measure: higher of 0 - 10 points on attainment or improvement

For each hospital, CMS aggregates scores across all measures
within a domain (e.g., clinical process-of-care measures,
HCAHPS)

CMS weights and combines each hospital’s domain scores to
determine the hospital’s Total Performance Score
CMS translates each hospital’s Total Performance Score into an
incentive payment using an exchange function



                                                                 7
     Scoring Performance

Scoring Based on Attainment
  0 to 10 points scored relative to the attainment
  threshold and the benchmark
  Thresholds and benchmarks determined from
  national hospital performance in prior year

Scoring Based on Improvement
  0 to 9 points for improvement based on hospital
  improving its score on the measure from its prior
  year performance.


                                                      8
Earning Clinical Process of Care Points:
                Example
         Measure: PN Pneumococcal Vaccination

                              .47                                               .87
                        Attainment Threshold                            Benchmark
  Hospital I
       Score                                Attainment Range

  baseline                                              Score
         •
       .21
  performance                                           .70
                                    •   •   •   •   •
                                                         •
                                                         •      •   •       •
                                    1   2   3   4   5     6     7   8       9
                                            Attainment Range
                •
                1
                    •
                    2
                          •
                          3
                                    •
                                    4     •
                                          5    •
                                               6    •
                                                    7           •
                                                                8
                                                                        •
                                                                        9
                                    Improvement Range
         Hospital I Earns: 6 points for attainment
                           7 points for improvement
         Hospital I Score: maximum of attainment or improvement
                           = 7 points on this measure                                 11
Calculation of Clinical Process of Care
          Performance Score

   Total Earned Points =
    Sum of points earned across all reported measures

   Total Possible Points =
    Number of measures reported by hospital x 10

   Clinical Process of Care Performance Score =
   Total Earned Points / Total Possible Points x 100




                                                        12
      Calculation of VBP
   Total Performance Score

Each domain of measures is initially scored separately,
weighting each measure within that domain equally
All domain scores are then combined, with the
potential for different weighting by domain
Possible weighting to combine clinical process
measures and HCAHPS:
    70% clinical process + 30% HCAHPS
As new domains are added (e.g., outcomes), weights
will be adjusted

                                                   16
            Translating Performance Score into
               Incentive Payment: Example
            100%
            90%
            80%
                                                          Hospital A
            70%
 Percent
            60%
 Of VBP
Incentive   50%
Payment
 Earned     40%
            30%
            20%
            10%
             0%
                   0%   10%   20%   30%   40%   50%    60%    70%      80%    90%         100%
                                    Hospital Performance Score:
                                                                         Full Incentive
                                        % Of Points Earned
                                                                            Earned               18
Source of Incentive Payments


 VBP incentive proposed to be a percent of
 base operating DRG payment
   Base payment would include geographic and
   DRG relative weight adjustments
   Approach links incentive payment most directly
   to clinical services provided
   Would apply to all DRGs, not just clinical areas
   measured




                                                      19
   Allocation of Unearned
    Incentive Payments

Not all hospitals would earn the full VBP
incentive payment
Pool of unearned incentive dollars could be
the source of additional quality incentive
distributed to hospitals and/or Medicare
savings
Additional quality incentive would be
distributed to hospitals in proportion to
their VBP Total Performance Scores

                                              20
 VBP Measures Overview

Measure selection considerations
Proposed process for introducing and
managing measures in VBP
FY 2009 candidate measures for VBP
financial incentive
Additional measures for FY 2010 and
beyond
Small numbers issue


                                       21
Proposed Measure Selection
 Criteria for VBP Incentive

 NQF
   Importance
   Scientific acceptability
   Feasibility
   Usability

 Additional CMS
   Improvability
   Controllability
   Potential for unintended consequences
   Contribution to comprehensiveness

                                           22
            Proposed Process for Introducing Newly
            Developed Measures into VBP Program
            Measure Development,                                            Measure Introduction
            Testing, Endorsement
       Stakeholder Involvement:               NQF
      HQA, Joint Commission, and          Endorsement†                           VBP Program
                 others



  Identified                                             Preliminary                Public                     Include for
                           Measure
   Gap in                                                   Data                 Reporting &                   Payment &
                          Development
   Existing                                              Submission              Baseline Data                   Public
                           & Testing
  Measures                                                 Period                  for VBP                      Reporting


                                         Existing  VBP Measure                                 Thresholds for
                                        Measures     Selection                                   Payment
                                      from Outside    Criteria                                  Determined
                                         Entities*    Applied

*Measures without substantial field   †
                                       Measures will be submitted for NQF endorsement, but need not await final
experience will be tested as needed   endorsement before proceeding to the next step in the introduction process             23
         FY 2009 Candidate Measures for
             VBP Financial Incentive
Clinical Quality Process-of-Care Measures – Acute         Entered Public
Myocardial Infarction (AMI)                               Reporting on Hospital
                                                          Compare
AMI-1     Aspirin at arrival                              4/2005
AMI-2     Aspirin prescribed at discharge                 4/2005


AMI-3     ACE inhibitor (ACE-I)/Angiotensin receptor      4/2005
          blocker (ARB) for left ventricular systolic
          dysfunction

AMI-4     Adult smoking cessation advice/counseling       4/2005
AMI-5     Beta blocker at discharge                       4/2005
AMI-7a    Thrombolytic agent received within 30 minutes   4/2005
          of hospital arrival
AMI-8a    Primary percutaneous coronary intervention      4/2005
          (PCI) received within 90 minutes of hospital
          arrival

                                                                                  25
 FY 2009 Candidate Measures for
     VBP Financial Incentive
Clinical Quality Process-of-Care Measures –   Entered Public
Heart Failure (HF)                            Reporting on
                                              Hospital Compare
HF-1     Discharge instructions               4/2005

HF-3     ACE inhibitor (ACE-I)/Angiotensin    4/2005
         receptor blocker (ARB) for left
         ventricular systolic dysfunction

HF-4     Adult smoking cessation              4/2005
         advice/counseling




                                                                 26
        FY 2009 Candidate Measures for
            VBP Financial Incentive
Clinical Quality Process-of-Care Measures –                Entered Public
Pneumonia (PN)                                             Reporting on
                                                           Hospital Compare

PN-2      Pneumococcal vaccination status                  4/2005

PN-3b     Blood culture performed in emergency             4/2005
          department before first antibiotic received in
          hospital

PN-4      Adult smoking cessation counseling               4/2005


PN-6      Appropriate antibiotic selection                 9/2005


PN-7      Influenza vaccination status                     12/2006
                                                                              27
 FY 2009 Candidate Measures for
     VBP Financial Incentive

Surgical Care Improvement/Surgical                   Entered Public
Infection Prevention (SCIP/SIP)                      Reporting on
                                                     Hospital Compare

SCIP-   Prophylactic antibiotic selection received   9/2005
Inf-1   within 1 hour prior to surgical incision



SCIP-   Prophylactic antibiotics discontinued        9/2005
Inf-3   within 24 hours after surgery end time




                                                                        28
       FY 2009 Candidate Measures for
           VBP Financial Incentive

Clinical Quality – Outcome Measures   Scheduled to Enter
                                      Public Reporting on
                                      Hospital Compare



          30-day AMI mortality        6/2007

          30-day HF mortality         6/2007

Patient-Centered Care Measures

          HCAHPS                      3/2008


                                                            29
 HCAHPS Dimensions

Communication with Doctors
Communication with Nurses
Responsiveness of Hospital Staff
Cleanliness and Quiet of Hospital
Environment
Pain Management
Communication about Medicines
Discharge Information
Overall Rating
                                    30
      Additional Measure Topics for
          FY 2010 and Beyond
FY 2010–FY 2011              FY 2012 and Beyond

Efficiency measures          Performance areas to
Outcomes measures            address measure gaps
Emergency care measures      Expect need for new
Care coordination measures   measure development
Patient safety measures
Structural measures
Hospital VBP Report to Congress



• The Hospital Value-Based Purchasing Report
  Congress can be downloaded from the CMS
  website at:
  http://www.cms.hhs.gov/center/hospital.asp
      VBP Initiatives




Hospital-Acquired Conditions
 and Present on Admission
     Indicator Reporting
 Value-Based Purchasing and
 Hospital-Acquired Conditions

• The Hospital-Acquired Conditions payment
  provision is a step toward Medicare VBP for
  hospitals
• Strong public support for CMS to pay less for
  conditions that are acquired during a
  hospital stay
• Considerable national press coverage of HAC
  has prompted dialogue of how to further
  eliminate healthcare-associated infections
  and conditions
              The HAC Problem


• The IOM estimated in 1999 that as many as
  98,000 Americans die each year as a result
  of medical errors
• Total national costs of these errors estimated
  at $17-29 billion
  IOM: To Err is Human: Building a Safer Health System, November 1999.
  Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf.
              The HAC Problem


• In 2000, CDC estimated that hospital-
  acquired infections add nearly $5 billion to
  U.S. health care costs annually
  Centers for Disease Control and Prevention: Press Release, March 2000.
  Available at: http://www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm.


• A 2007 study found that, in 2002, 1.7 million
  hospital-acquired infections were associated
  with 99,000 deaths
  Klevens et al. Estimating Health Care-Associated Infections and
  Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April
  2007. Volume 122.
              The HAC Problem


• A 2007 Leapfrog Group survey of 1,256
  hospitals found that 87% of those hospitals
  do not consistently follow recommendations
  to prevent many of the most common
  hospital-acquired infections
  2007 Leapfrog Group Hospital Survey. The Leapfrog Group 2007.
  Available at:
  http://www.leapfroggroup.org/media/file/Leapfrog_hospital_acquired_
  infections_release.pdf
     Statutory Authority:
     DRA Section 5001(c)

Beginning October 1, 2007, IPPS hospitals
were required to submit data on their claims
for payment indicating whether diagnoses
were present on admission (POA)

Beginning October 1, 2008, CMS cannot
assign a case to a higher DRG based on the
occurrence of one of the selected conditions,
if that condition was acquired during the
hospitalization
 Statutory Selection Criteria



CMS must select conditions that are:
1. High cost, high volume, or both
2. Assigned to a higher paying DRG when
   present as a secondary diagnosis
3. Reasonably preventable through the
   application of evidence-based guidelines
   Statutory Selection Criteria


• Burden
  – Incidence, cost, morbidity, and mortality

• Coding
  – Events appropriately detected using ICD-9 codes

• Preventability
  – Guidelines and interventions exist
  – Application can prevent these infections
     • Interpretation of “reasonably”
 Statutory Selection Criteria


Condition must trigger higher payment
  Complications, including infections, can be
  designated complicating conditions (CCs) or major
  complicating conditions (MCCs)
  MS-DRGs may split into three different levels of
  severity, based on complications (no CC or MCC,
  CC, or MCC)
    The presence of a CCs or MCCs as a secondary diagnosis
    on a claim generates higher payment
           MS-DRG Assignment                     POA Status of   Average
 (Examples for a single secondary diagnosis)      Secondary      Payment
                                                    Diagnosis
Principal Diagnosis: MS-DRG 066                       --         $5,347.98
• Stroke without CC/MCC
Principal Diagnosis: MS-DRG 065
• Stroke with CC                                      Y          $6,177.43
Example Secondary Diagnosis:
• Injury due to a fall (code 836.4 (CC))
Principal Diagnosis: MS-DRG 065
• Stroke with CC                                      N          $5,347.98
Example Secondary Diagnosis:
• Injury due to a fall (code 836.4 (CC))
Principal Diagnosis: MS-DRG 064
• Stroke with MCC                                     Y          $8,030.28
Example Secondary Diagnosis:
• Stage III pressure ulcer (code 707.23 (MCC))
Principal Diagnosis: MS-DRG 064
• Stroke with MCC                                     N          $5,347.98
Example Secondary Diagnosis:
• Stage III pressure ulcer (code 707.23 (MCC))
      HACs Selected During
    IPPS FY 2008 Rulemaking

• Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection
• Vascular catheter-associated infection
• Surgical site infection – mediastinitis after
  CABG
• Pressure ulcers
• Falls – specific trauma codes
                   Medicare Data        CC/MCC          Selected
Selected HAC         (FY 2007)         (ICD-9-CM      Evidence-Based
                                         Codes)         Guidelines
                                                       NQF Serious
Foreign Object    ● 750 cases           998.4 (CC) Reportable Adverse
Retained After    ● $63,631/hospital    998.7 (CC)         Event
Surgery              stay                          www.ahrq.gov/
                                                   qual/nqfpract.htm

                                                       NQF Serious
Air Embolism      ● 57 cases           999.1 (MCC) Reportable Adverse
                  ● $71,636/hospital                       Event
                     stay                          www.ahrq.gov/
                                                   qual/nqfpract.htm

                                                       NQF Serious
Blood             ● 24 cases            999.6 (CC) Reportable Adverse
Incompatibility   ● $50,455/hospital                       Event
                     stay                          www.ahrq.gov/
                                                   qual/nqfpract.htm
                                         CC/MCC           Selected
Selected HAC       Medicare Data        (ICD-9-CM        Evidence-Base
                     (FY 2007)            Codes)          d Guidelines


Catheter-         ● 12,185 cases          996.64 (CC) www.cdc.gov/
Associated        ● $44,043/hospital                  ncidod/dhqp/
Urinary Tract       stay                Also excludes gl_catheteassoc.
Infection (UTI)                        the following  html
                                       from acting as
                                       a CC/MCC:
                                           112.2 (CC)
                                          590.10 (CC)
                                        590.11 (MCC)
                                         590.2 (MCC)
                                           590.3 (CC)
                                          590.80 (CC)
                                          590.81 (CC)
                                           595.0 (CC)
                                           597.0 (CC)
                                           599.0 (CC)
                  Medicare Data       CC/MCC           Selected
Selected HAC        (FY 2007)        (ICD-9-CM       Evidence-Based
                                       Codes)          Guidelines
                                                  Available at the Web
Vascular         ● 29,536 cases       999.31 (CC) site:
Catheter-        ●$103,027/hospita                http://www.cdc.gov/
Associated          l stay
Infection                                         ncidod/dhqp/
                                                  gl_intravascular.html


                                                  Available at the Web
Surgical Site    ● 69 cases          519.2 (MCC)     site:
Infection-       ●$299,237/hospita And one of the http://www.cdc.gov/
Mediastinitis      l stay          following      ncidod/dhqp/
after Coronary                     procedure      gl_surgicalsite.html
Artery Bypass                      codes:
Graft (CABG)                          36.10–36.19
                   Medicare Data       CC/MCC          Selected
Selected HAC         (FY 2007)        (ICD-9-CM      Evidence-Based
                                        Codes)         Guidelines
                                                      NQF Serious
Stage III & IV  ● 257,412 cases      707.23 (MCC) Reportable Adverse
Pressure Ulcers ●$43,180/hospital    707.24 (MCC)         Event
                   stay                           www.ncbi.nl.nih.go/
                                                  books/bv.fcgi?rid=
                                                  hstat2.chapter.4409
                                    CC/MCC
Falls and         ● 193,566 cases      codes          NQF Serious
Trauma:           ●$33,894/hospital within these   Reportable Adverse
                     stay           ranges:               Event
 - Fractures                                       www.ahrq.gov/
 - Dislocations                     800-829        qual/nqfpract.htm
 - Intracranial                     830-839
    Injuries                        850-854
 - Crushing                         925-929
    Injuries                        940-949
 - Burns
                                    991-994
            Candidate HACs

•   Surgical site infections following specific elective
    procedures
•   Staphylococcus aureus septicemia
•   Clostridium difficile-associated disease (CDAD)
•   Ventilator-associated pneumonia (VAP)
•   Deep vein thrombosis (DVT) / pulmonary embolism
    (PE)
•   Legionnaires’ Disease
•   Iatrogenic pneumothorax
•   Delirium
•   Extreme glycemic aberrancies
                   Medicare Data          CC/MCC             Selected
HAC Candidate        (FY 2007)           (ICD-9-CM       Evidence-Based
                                            Codes)           Guidelines
Surgical Site     Total Knee           Total Knee
Infections        Replacement          Replacement       www.cdc.gov/
Following         ● 539 cases          (81.54):          ncidod/dhqp/
Elective          ● $63,135/hospital       996.66 (CC)   gl_surgicalsite.
Procedures:          stay                          and   html
 - Total Knee     Laparoscopic             998.59 (CC)
   Replacement    Gastric Bypass
 - Laparoscopic      and               Laparoscopic    www.cdc.gov/
   Gastric        Gastroenterostomy    Gastric Bypass ncidod/dhqp/
   Bypass and     ● 208 cases          (44.38)         glisolation.html
   Gastroenter-   ●$180,142/hospital   and
   ostomy            stay              Gastroenter-
 - Ligation and   Ligation and         ostomy (44.39):
   Stripping of   Stripping of             998.59 (CC)
   Varicose       Varicose Veins
   Veins          ● 3 cases            Varicose Veins
                  ● $66,355/hospital   (38.5):
                     stay                  998.59 (CC)
                   Medicare Data       CC/MCC            Selected
HAC Candidate        (FY 2007)        (ICD-9-CM      Evidence-Based
                                         Codes)          Guidelines
                                                    www.cdc.gov/
Staphylococcus   ● 27,737 cases        038.11(MCC) ncidod/dhqp/
aureus           ● $84,976/hospital   995.91 (MCC) gl_isolation.html
Septicemia          stay              995.92 (MCC)
                                        998.59 (CC) www.cdc.gov/
                                         999.3 (CC) ncidod/dhqp/gl_
                                                    itravascular.html

                 ● 96,336 cases                    www.cdc.gov/
Clostridium      ● $59,153/hospital    008.45 (CC) ncidod/dhqp/
difficile-         stay                            gl_isolation.html
Associated
Disease(CDAD)                                        www.cdc.gov/
                                                     ncidod/dhqp/
                                                     id_CdiffFAQ_
                                                     HCP.html#9
                 Medicare Data        CC/MCC            Selected
HAC Candidate      (FY 2007)         (ICD-9-CM      Evidence-Based
                                        Codes)          Guidelines
                                                    www.rcjournal.
Ventilator-     ● 30,867 cases          997.31 (CC) com/cpgs/09.03.
Associated      ●$135,795/        Must also include 0869.html
Pneumonia
(VAP)             hospital stay   ventilator codes:
                                      96.70 – 96.72


Deep Vein       ● 149,010 cases    453.40 – 453.42 www.chestjournal.
Thrombosis      ●$50,937/                     (CC) org/cgi/reprint/
(DVT) /                              415.11 (MCC) 126/3_suppl/172S
Pulmonary         hospital stay      415.19 (MCC)
Embolism (PE)                                      orthoinfo.aaos.org
                                                      /topic.cfm?topi
                                                      c=A00219
                 Medicare Data       CC/MCC           Selected
HAC Candidate      (FY 2007)        (ICD-9-CM     Evidence-Based
                                       Codes)         Guidelines
                                                 www.cdc.gov
Legionnaires’   ● 351 cases         482.84 (MCC) /ncidod/dbmd/
Disease         ●$86,014/hospital                diseaseinfo/
                   stay                          legionellosis_g.
                                                 htm

                                                  www.legionella.
                                                    org/
                                                 www.ncbi.nlm.
Iatrogenic      ● 22,665 cases        512.1 (CC) nih.gov/pubmed/
Pneumothorax    ●$75,089/hospital                   1485006
                   stay

                                                 www.ahrq.gov/
Delirium        ● 480 cases           293.1 (CC) clinic/ptsafety/
                ●$23,290/hospital                chap28.htm
                   stay
                     Medicare Data          CC/MCC             Selected
HAC Candidate          (FY 2007)           (ICD-9-CM       Evidence-Based
                                              Codes)           Guidelines
                                          Diabetic
Extreme           Diabetic Ketoacidosis   Ketoacidosis:    NQF Serious
Glycemic          ● 11,469 cases                 250.10–   Reportable
                                                  250.13
Aberrancies:      ● $42,974/hosp stay               (CC)   Adverse Events
 - Diabetic       Nonketotic              Nonketotic       Address
   Ketoacidosis   Hyperosmolar Coma       Hyperosmola      hypoglycemia
 - Nonketotic     ● 3,248 cases           Coma:
   Hyperosmolar   ● $35,215/hosp stay            250.20–   www.diabetes.
                                                  250.23
   Coma           Diabetic Coma                     (CC)   org/uedocume
 - Diabetic       ● 1,131 cases           Diabetic         nts/InpatientDM
   Coma           ● $45,989/hosp stay     Coma:            GlycemicControl
 -Hypoglycemic    Hypoglycemic Coma        250.3 -250.33      PositionStmt0
   Coma           ● 212 cases                       (CC)      2.01.06.REV.
                                          Hypoglycemic        pdf
                  ● $36,581/hosp stay
                                          Coma:
                                             251.0 (CC)
 Present on Admission (POA)




CMS’ Implementation of POA
     Indicator Reporting
POA Indicator General Requirements


•   Present on admission is defined as present at
    the time the order for inpatient admission
    occurs
    – Conditions that develop during an outpatient
      encounter, including emergency department,
      observation, or outpatient surgery, are considered
      present on admission

•   Phased implementation
POA Indicator General Requirements



• POA indicator is assigned to
  – Principal diagnosis
  – Secondary diagnoses
  – External cause of injury codes (Medicare
    requires reporting only if E-code is
    reported as an additional diagnosis)
        POA Indicator Reporting Options
POA Indicator Options and Definitions
Code    Reason for Code
  Y     Diagnosis was present at time of inpatient admission.
  N     Diagnosis was not present at time of impatient admission.
  U     Documentation insufficient to determine if condition was
        present at the time of inpatient admission.
  W     Clinically undetermined. Provider unable to clinically
        determine whether or not the condition was present at the time
        of inpatient admission or not.
   1    Unreported/Not used. Exempt from POA reporting. This code
        is equivalent code of a blank on the UB-04, however, it was
        determined that blanks are undesirable when submitting this
        data via the 4010A.
     POA Indicator Reporting
   IPPS FY 2009 Proposed Rule



• POA indicator
  – CMS is proposing to pay the CC/MCC for
    HACs that are coded as “Y” & “W”
  – CMS is proposing to NOT pay the CC/MCC
    for HACs that are coded “N” & “U”
      POA Indicator Reporting
  Requires Accurate Documentation


“ A joint effort between the healthcare provider
  and the coder is essential to achieve
  complete and accurate documentation, code
  assignment, and reporting of diagnoses and
  procedures.”

ICD-9-CM Official Guidelines for Coding and Reporting
IPPS FY 2009 Proposed Rule




      HAC & POA
   Enhancement and
     Future Issues
              HAC & POA
       Enhancement & Future Issues

• CMS seeks public comment on enhancements to the
  HAC payment provision in the IPPS FY 2008 proposed
  rule
   – Risk adjustment
   – Rates of HACs for VBP
   – Uses of POA information
   – Adoption of ICD-10
   – Expansion of the IPPS HAC payment provision to other
     settings
   – Relationship to NQF’s Serious Reportable Adverse Events
      Relationship of HACs to
       NQF’s “Never Events”

• In 2002, NQF created a list of 27 Serious
  Reportable Adverse Events, which was
  expanded to 28 events in 2006
• Of the HACs selected during IPPS FY 2008
  rulemaking, 7 are on NQF’s list
• Of the HACs candidates under consideration
  durng IPPS FY 2009 rulemaking, 1 overlaps
  with NQF’s events
      Relationship of HACs to
       NQF’s “Never Events”

• NQF’s selection criteria for Serious Reportable
  Adverse Events
  – Unambiguous: clearly identifiable and measurable
  – Usually preventable: recognizing that some events
    are not always avoidable
  – Serious: resulting in death or loss of a body part,
    disability, or more transient loss of a body function
  – Indicative of a problem in a health care facility’s
    safety systems
  – Important for public credibility or public
    accountability
    NQF’s Serious Reportable Adverse Events             HAC
                    Surgical Events
Surgery on wrong body part

Surgery on wrong patient

Wrong surgery on a patient

Foreign object left in patient after surgery           Selected
Post-operative death in normal health patient

Implantation of wrong egg
              Product or Device Events
Death/disability associated with use of contaminated
drugs, devices, or biologics
Death/disability associated with use of device other
than as intended
Death/disability associated with intravascular air
                                                       Selected
embolism
 Current NQF Serious Reportable Adverse Events             HAC
              Patient Protection Events
Infant discharged to wrong person
Death/disability due to patient elopement
Patient suicide or attempted suicide resulting in
disability
              Care Management Events
Death/disability associated with medication error

Death/disability associated with incompatible blood      Selected
Maternal death/disability with low risk delivery

Death/disability associated with hypoglycemia            Candidate
Death/disability associated with hyperbilirubinemia in
neonates
Stage 3 or 4 pressure ulcers after admission             Selected
Death/disability due to spinal manipulative therapy
  Current NQF Serious Reportable Adverse Events               HAC
                   Environment Events
Death/disability associated with electric shock              Selected
Incident due to wrong oxygen or other gas
Death/disability associated with a burn incurred within
                                                             Selected
facility
Death/disability associated with a fall within facility      Selected
Death/disability associated with use of restraints within
facility
                      Criminal Events
Impersonating a heath care provider (i.e., physician,
nurse)
Abduction of a patient
Sexual assault of a patient within or on facility grounds

Death/disability resulting from physical assault within or
on facility grounds
       Combating Never Events

•   HAC payment provision
•   Conditions of Participation
•   VBP Plan—measurement, financial incentives, and
    public reporting
•   Coverage policy
•   Quality Improvement Organization activities
•   The President’s FY 2009 Budget proposal
    1. Prohibit hospitals from billing Medicare for never events
    2. Require hospitals to report occurrence of these events or
       receive a reduced annual payment update
 Opportunities for HAC & POA
        Involvement

IPPS Rulemaking
  IPPS FY 2009 proposed rule on display April 14,
  2008
     60 day comment period ends on June 13,
     2008
  IPPS FY 2009 final rule released in August 2008
Updates to the CMS HAC & POA website:
www.cms.hhs.gov/HospitalAcqCond/
Hospital Open Door Forums
Hospital Listserv Messages
  Value-Driven Health Care


Executive Order
CMS’ Posting of Quality and Cost
Information
Better Quality Information for Medicare
Beneficiaries Pilots
Chartered Value Exchanges
   Value-Driven Health Care

Executive Order 13410
  Promoting Quality and Efficient Health Care in
  Government Administered or Sponsored Health
  Care Programs
  Directs Federal Agencies to:
    Encourage adoption of health information technology
    standards for interoperability
    Increase transparency in healthcare quality measurements
    Increase transparency in healthcare pricing information
    Promote quality and efficiency of care, which may include
    pay for performance
   Horizon Scanning and
Opportunities for Participation

IOM Payment Incentives Report
  Three-part series: Pathways to Quality Health Care
MedPAC
  Ongoing studies and recommendations regarding value-based
  purchasing tools
Congress
  VBP legislation this session?
CMS Proposed Regulations
  Seeking public comment on the VBP building blocks
CMS Demonstrations and Pilots
  Periodic evaluations and opportunities to participate
   Horizon Scanning and
Opportunities for Participation

CMS Implementation of MMA, DRA, and TRHCA
provisions
   Demos, P4R programs, VBP planning
Measure Development
   Foundation of VBP
Value-Driven Health Care Initiative
   Expanding nationwide
Quality Alliances and Quality Alliance Steering
Committee
   AQA Alliance and HQA adoption of measure sets and
   oversight of transparency initiative
           Thank You



Thomas B. Valuck, MD, JD
  Medical Officer & Senior Adviser
  Center for Medicare Management
  Centers for Medicare & Medicaid Services

				
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